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SDE Versus HDE

Question Type:
Intervention
Full Question:
In adult patients in cardiac arrest in any setting (P), does does HDE (at least 0.2 mg/kg or 5 mg bolus dose)  (I), compared with compared with SDE (1 mg bolus dose)  (C), change survival to 180 days with good neurological outcome, survival to 180 days, survival to hospital discharge with good neurological outcome, survival to hospital discharge, ROSC (O)?
Consensus on Science:
For the critical outcome of survival to hospital discharge with CPC 1 or 2, we found very- low-quality evidence (downgraded for very serious indirectness and serious imprecision) from 2 RCTs comparing SDE with HDE(Callaham 1992, 2667; Gueugniaud 1998, 1595) (n=1920) and cumulative RR that did not show any CPC 1 or 2 survival to discharge advantage with HDE (RR, 1.2; 95% CI, 0.74–1.96; ARR, −0.4%, 95% CI, −1.2 to 0.5, which translates to 3 fewer patients/1000 surviving to discharge with a CPC score of 1 or 2 [95% CI, 12 fewer to 5 more patients/1000 surviving to discharge with a CPC score of 1–2]). For the critical outcome of survival to hospital discharge, we found very-low-quality evidence (downgraded for very serious indirectness and serious imprecision) from 5 RCTs comparing SDE with HDE(Brown 1992, 1051; Callaham 1992, 2667; Stiell 1992, 1045; Sherman 1997, 242; Gueugniaud 1998, 1595) (n=2859) that did not show any survival to discharge advantage with HDE (RR, 0.97; 95% CI, 0.71–1.32; ARR, −0.1%; 95% CI, −0.1 to 0.7, which translated to 1 fewer patient/1000 surviving to discharge with HDE [95% CI, 10 fewer patients/1000 to 7 more patients/1000]).For the important outcome of survival to hospital admission, we found low-quality evidence (downgraded for very serious indirectness) from 4 RCTs comparing SDE with HDE(Brown 1992, 1051; Callaham 1992, 2667; Choux 1995, 3; Gueugniaud 1998, 1595) (n=2882) showing a survival to hospital admission advantage with HDE (RR, 1.15; 95% CI, 1.0–1.32). For the important outcome of ROSC, we found low-quality evidence (downgraded for very serious indirectness) from 6 RCTS comparing SDE with HDE(Brown 1992, 1051; Callaham 1992, 2667; Stiell 1992, 1045; Choux 1995, 3; Sherman 1997, 242; Gueugniaud 1998, 1595) (n=3130) showing a ROSC advantage with HDE (RR, 1.17; 95% CI, 1.03–1.34).
Treatment Recommendation:
We suggest against the routine use of HDE in cardiac arrest (weak recommendation, low-quality evidence).
Values, Preferences, and Task Force Insights:
In making this statement, we acknowledge that HDE improves short-term outcomes but note that the low-quality evidence failed to show an improvement in the critical outcomes of survival and neurologic outcome. The absolute magnitude of effects of HDE versus SDE on ROSC (RR, 1.17; 95% CI, 1.03–1.34) and admission to hospital (RR, 1.15; 95% CI, 1.0–1.32) are modest. These HDE studies were published in the 1990s, and since then care and outcomes for cardiac arrest have changed dramatically, making it hard to interpret the relevance of these results for current care.
CoSTR Attachments:
C2015_Worksheet_ALS_Vasopressors in cardiac arrest Jan 2 2015_n.docx    
PRISMA Checklist for Vasopressor SR and MA_n.docx    
SDE vs. HDE_n.docx    
work sheet on vaso Feb 6 2015_n.docx    

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